Medicare Advantage plans are experiencing a fundamental shift in how patient risk gets calculated and reimbursed. The HCC Model V24 to V28 transition isn't just another regulatory update; it's reshaping revenue streams for healthcare organizations nationwide. As part of CMS’s transition to the V28 model, Medicare Advantage payments are expected to decrease gradually over time, creating both financial pressure and the need for strategic adaptation among providers.
The stakes are high. Some conditions now carry lower weights, while others show significant increases in coefficients. Understanding these changes will make the difference between a prosperous and a struggling organization, particularly with the new model of risk adjustment. This change places greater importance on documentation practices, coding accuracy, and the effective use of technology.
What is the V28 Risk Adjustment Model?
The V28 model represents CMS's updated methodology for calculating RAF scores in Medicare Advantage and specific Medicare health plans. It replaces the V24 model with modified HCC categories, adjusted coefficients, and stricter coding requirements.
Key changes include:
Removal of 2,294 ICD-10 diagnosis codes from HCC risk adjustment mapping
Constrained coefficients for prevalent conditions
Introduction of Payment Condition Categories (PCCs), which account for the combined impact of multiple serious or interacting conditions
Higher relative factors for immunity disorders and chronic ulcers
The model aims to improve accuracy in risk adjustment while reducing overall Medicare spending.
How Does V28 Change RAF Score Calculations?
RAF scores under V28 follow a different weighting system compared to V24. The model assigns risk scores based on patient demographics, disease severity, and diagnosed conditions captured through ICD-10 codes.
Phased Implementation Timeline
CMS rolled out the HCC Model V24 to V28 gradually to ease the transition:
2023: 33% V28 + 67% V24
2024: 67% V28 + 33% V24
2025: 100% V28 (full adoption)
This phased approach gives organizations time to adjust coding practices and prepare for revenue impacts.
Coefficient Adjustments
V28 constrains coefficients across certain condition categories, reducing variation in weights that previously reflected differences in disease severity. The constrained HCC coefficients for diabetes, heart failure, COPD, and major depressive disorders reduce variation across severity levels compared to V24.
Organizations Most Impacted by Lower RAF Scores Under V28
Under the V28 new risk adjustment model, several common chronic conditions carry lower relative risk weights compared to V24. In illustrative scenarios, a 67-year-old male with diabetes may see a lower RAF score under V28 compared to V24, reflecting reduced coefficients for common chronic conditions.
Conditions with lower coefficients include:
Type 2 diabetes mellitus
Congestive heart failure
Chronic obstructive pulmonary disease
Major depressive and bipolar disorders
These changes mean providers can no longer rely on high-volume chronic diagnoses alone to maintain prior revenue levels.
Organizations Benefit Most from Higher RAF Values Under V28
Not all conditions see decreases. V28 significantly increases coefficients for specific complex conditions, creating new opportunities for accurate documentation and coding.
High-Value HCCs to Prioritize
Organizations should focus on these conditions with higher RAF values:
Ulcers of skin: Substantial coefficient increase
Rheumatoid arthritis: Enhanced weight recognition
End-stage heart failure (HCC222): Higher severity acknowledgment
Idiopathic pulmonary fibrosis and lung involvement in systemic sclerosis (HCC278): Increased recognition of complexity
Chronic kidney disease, stage 5 (HCC326): Higher reimbursement potential
In contrast, patients with multiple complex conditions may experience higher RAF scores under V28, reflecting the model’s greater emphasis on clinical complexity.
Why Were 2,294 ICD-10 Codes Removed from HCC Mapping?
CMS removed these codes to enhance the specificity of risk adjustment. Codes ceasing to map to HCCs will not add to RAF scores, and it is essential to have complete documentation to capture all eligible conditions.
This change requires:
Regular review of coding practices
Training for clinical staff on V28 mappings
Technology systems that flag unmapped codes
Documentation that supports all billable diagnoses
Incomplete coding can result in underreported risk and reduced reimbursement. Organizations need systems that identify these gaps at the point of care.
How Can Providers Mitigate Revenue Loss Under V28?
The HCC Model V24 to V28 transition creates financial pressure, but strategic actions minimize revenue impact.
Focus on Documentation Accuracy
Full clinical records make sure that all the pertinent conditions are recorded. Providers are expected to record chronic conditions at each encounter where they are discussed with the most specific ICD-10 codes possible.
Leverage Technology for Real-Time Insights
Digital health platforms enable real-time identification of HCC documentation opportunities during patient encounters. These systems put V24 and V28 side by side, which assists providers in seeing the specific impacts of the coding choice on reimbursement.
Prioritize Complex Condition Capture
Patients with multiple qualifying and interacting conditions may benefit from PCCs when documentation reflects their combined clinical complexity. Thorough documentation of all comorbidities maximizes these additional weights.
Monitor RAF Score Changes
Patient Profile | V24 RAF Score | V28 RAF Score | Change |
67-year-old male with diabetes | 1.062 | 0.97 | -8.7% |
Patient with multiple complex conditions | 2.775 | 5.332 | +92.1% |
These comparisons reveal where organizations need to adjust their documentation strategies.
What Role Does Technology Play in V28 Success?
Healthcare organizations need robust technology solutions to navigate V28's complexity. The systems should consolidate clinical, claims, and social determinants of health data to develop a complete longitudinal patient record.
Key technology capabilities include:
Real-time HCC opportunity identification at the point of care
Side-by-side V24 and V28 code comparison
Automated alerts for documentation gaps
RAF score impact analysis
EHR-agnostic integration
These capabilities help providers make more informed coding decisions during clinical encounters rather than relying on retrospective reviews.
Takeaway
The transition from HCC Model V24 to V28 fundamentally changes how Medicare Advantage plans calculate RAF scores and assess patient risk. Organizations that strengthen documentation practices, focus on high-value HCCs, and use technology effectively are better positioned to manage revenue impact under V28.
Optimize Your V28 Revenue with Persivia
Persivia CareSpace® is an AI-driven platform that helps organizations navigate V28 by aggregating clinical, claims, and SDOH data into accurate longitudinal records. Through CareTrak®, it provides real-time, EHR-agnostic HCC insights with side-by-side V24 and V28 code comparisons to analyze RAF impact. With 15 years of expertise, Persivia enables better coding accuracy, optimized reimbursements, and stronger value-based care performance.